Hot flashes, night sweats, brain fog, weight gain, belly fat, joint pain, hair shedding, bloating… We all know the many, many symptoms of menopause.
What is rarely discussed is what happens ‘down south’ when our hormones decline, how menopause affects the delicate tissues of the vagina, the vaginal canal, and even the bladder and urinary tract.
In fact, after being in clinical practice since 2004, I recall that some women would struggle to discuss the changes they were experiencing with me. And those of you who know me know that I’m open to talking about anything and easy to talk to.
But it can feel awkward talking about having an itchy or dry vagina. It can be hard to talk about UTIs, odor, leakage, or sex that is painful.
If it’s hard to talk with me (dimples and all), I can imagine how awkward it could be with a male doctor, or a doc that is hurried or rushed.
So, for this article, let’s talk about GSM (genitourinary syndrome of menopause).
GSM is basically an umbrella term for the cluster of vulvar, vaginal, urinary, and sexual symptoms caused by estrogen deficiency during menopause.
What happens to the vagina, vaginal vault, bladder, and urethra when estrogen and progesterone decline in menopause?
Because it's way more than just dryness.
And if you are familiar with my writings, well, I love using avatars and stories to explain physiology and women’s health.
I Bled, And Now He Won’t Come Near Me
Hi, I’m Sue, and I’m going to come out and say it. It’s like the Sahara Desert down there. I’m 55 years old, and I have not had a period for at least 5 years, maybe 6? Which is great, certainly don’t miss Aunt Flo every month.
But I’m having this issue… a delicate issue that's really impacting my life and my relationship with my husband, Todd.
When we are intimate, it’s like sandpaper, or it feels like sandpaper. I have always had a high libido, and Todd is fantastic. But it’s very dry, and it feels like all the lube in the world is not helping.
It hurts, and it feels the worst where the opening is. Sorry for the TMI. It feels weird to even be talking about this.
In fact, the area down there seems smaller, or not like it used to, if that makes sense. My mother would be horrified to even know I am saying these things out loud.
But what is really making me talk about this is Todd. The other night, we, I guess, tried, and I bled. There was red blood. Remember, no period for years, so it wasn’t a period.
He completely freaked out. And now he won’t even try to be intimate. He is so worried that he is hurting me. It’s not that he is grossed out; he’s just convinced he might hurt me, and that worries him. Plus, it kinda puts a bit of a damper on his own response in the bedroom, if you know what I mean. What can I do? Is this my new normal?
So what is going on here?
There are many estrogen receptors in the vaginal tissues, especially in the introitus. The introitus is the opening of the vaginal vault.
When estrogen drops in menopause, the vaginal tissues:
- Lose elasticity
- Collagen decreases
- Skin becomes thinner
- There is less blood flow to the vaginal area
- Less natural lubrication
- Introitus (opening) can feel smaller, not stretchy, tight, or like it is closing.
All of this can lead to what Sue experienced: bleeding and pain with intercourse.
This is not Sue or Todd’s fault; they are doing nothing wrong. It is what happens when the estrogen drops in menopause. While it might be easier to talk about the other symptoms of menopause, what happens to our sexual health should be part of the conversation. Because there are plenty of options (hormonal and non-hormonal) for GSM
What Can Sue Do?
If you want to read the full section on solutions for Sue — hormonal and non-hormonal — you can upgrade to the paid version of this newsletter.
UTIs Over and Over
Meet Ingrid
Again?! Omg, I cannot deal with this. Another UTI? This has got to be my 3rd UTI in the past 6-9 months.
I just came back from the clinic, and what an embarrassing, stressful situation.
I peed in the cup and saw the doc.
A different doc from my usual doctor. This guy looked about 12, I mean, 30.
He didn’t even read my chart.
Me: ‘I think I have a UTI.’
Dr. Burns: ‘I see, have you had a new sexual partner recently?’
Me: ‘I’m married.’
Dr. Burns (eye roll): ‘Have you had a new sexual partner recently?’
Me: ‘Wait, what? This is not a sexually transmitted disease! It’s a UTI. It’s the 3rd one I have had this year. Ask Dr. Hurtsenpee, he knows that I have chronic UTIs.’
Dr. Burns: ‘Here’s a script for some antibiotics. But you might want to check in with your partner.’
Me: ‘Check in with what?’
Dr. Burns: ‘You know, UTIs can come from…outside factors. And if you both need to get checked.’
Me: ‘Outside factors? Outside factors, like menopause?’
Dr. Burns: ‘I don’t know anything about hormones. Here’s a prescription for antibiotics.’
This is a common theme with GSM. With menopause can come an increased risk of UTIs.
There are many estrogen receptors in our urethra (the tube from our bladder to the outside
outside world, aka the toilet) and in our bladder.
When estrogen declines and disappears, it can cause changes to our bladder and urethra.
The urethral mucosa/tissues are thin, as well as the bladder can become more reactive.
This can lead to:
- Urgency
- Frequency
- Frequent nighttime urination
- Recurrent UTIs
- More prone to stress incontinence
BV, Why Me?
Meet Beverly, and she has bacterial vaginosis.
Oh gosh, what is that smell? I don’t think anyone else can smell it, and I am meticulous with being clean…well, down there. Then all of a sudden, there is a fishy-smell. It’s embarrassing. But the worst is that it hurts, burns, itches, and just feels really uncomfortable down there.
Okay, okay, I know, I am an adult. And I can talk about my vagina like it's my elbow. Or I should be able to do that. But I am embarrassed and don’t know who to talk to.
Did I catch something? I am single and in my 50s and not even dating anyone. Could I have some kind of STD/STI that was dormant for years and years, and now it's showing up? Can that happen?
It’s not like a yeast infection, bc I have had those in my younger years after taking antibiotics.
This is different, and I don’t know what to do. I don’t have a gyn doc at the moment, and yes, I know I need one.
I googled and went to the drugstore, but wasn’t really sure what to get. I got a pH strip test to test my vaginal moisture/secretions. The pH reading was high, so that must mean I have BV? Why do I have it? And how do I get rid of it?
While Beverly and Ingrid have issues that seem completely different from each other, they are actually stemming from the same origin: menopause.
But why the UTIs and BV?
- The microbiome of the vaginal vault can be altered with GSM, making a perfect environment for BV (Bacterial Vaginosis).
- The urethral tissues thin and lose tone. That leads to the perfect storm where bacteria (mainly e.coli) can climb right up the urethra to cause a UTI.
Loss of Glycogen
Estrogen tells your vaginal cells to store glycogen. Glycogen is a food source for your vaginal microbiome. In particular, Lactobacillus, which is the bacterium that produces acid.
When estrogen drops in menopause, those cells stop producing and releasing glycogen. This means the primary species of beneficial bacteria, Lactobacillus, will decline due to a lack of food source (glycogen). This ends up changing the pH of the vaginal vault.
The vaginal microbiome is supposed to be more on the acidic pH side (3.8-4.2 pH). So the loss of the Lactobacillus species can cause the pH of the vaginal canal to become more alkaline (pH>4.5). This higher pH (due to lack of Lactobacillus) is a perfect environment for Gardnerella to grow like wildfire (and feel like it) to cause BV (bacterial vaginosis).
What can Beverly and Ingrid do?
The goal to help prevent BV and chronic UTIs is to improve the vaginal environment. Correct the vaginal vault microbiome so that it is not hospitable to Gardnerella species, and to bacteria (mainly E.Coli) to get into the urethra and bladder.
Side note: UTIs can be serious. If not resolved, it can make its way up the ureters and into the kidney, causing a kidney infection (which can be very serious).
How to Restore a Healthy Vaginal Environment?
Welcome to the Land Down Under of Menopause!
Sue, Ingrid, and Beverly have done nothing wrong. But they happen to be the collateral damage of menopause. But there are options and solutions to GSM. Again, GSM is an umbrella term for the many, many issues that can happen ‘down-south’ with the decline of our hormones in menopause. It might not be the easiest thing to talk about, but I think we need to start the conversation.
Thank you for reading,
xo Dr Valorie
